PULMONARYQUESTIONNAIRE

NAME: _________________________ AGE:______ DOB:________________

DATE:____________ REQUESTINGPHYSICIAN:________________________

NOTE:PleasehelpusfindoutaboutyoubyfillingoutthePatientsideofthisformonpages14.Ifyoudontknowthe
answertooneofthequestions,askyourbedpartnerifhe/shecanansweritforyou.
PLEASELEAVECLINICIANSIDEBLANK.
___________________PATIENT________________________CLINICIAN___________________

Whyareyouheretoseeapulmonary(lung)doctor? CC
_____________________________________
_____________________________________

Checkoffanylungorbreathingproblemsorsymptoms:HPI
___Unabletocatchyourbreath
___Wheezing
___Highbloodpressure
___Heartmurmur
___Unabletosleeplayingflatorwithone(1)pillow
___Nightsweats
___Coughedupblood
___Chestpainsorpressure
___Shortnessofbreath
___Dizziness
___Swollenlegs
___Heartfailure
___Bluelipsorfingernails
___Legcrampswhenyouwalk

Haveyoueverhad:
___Apulmonaryfunctiontestorspirometry
___Apulmonarystresstest
___Abronchoscopyorbronchial/lungbiopsy
___Lungsurgery,includingremovalofalobe
___Anelectrocardiogram
___Heartsurgery
___Lungcancer
___Exposuretotuberculosisorhadtuberculosis
___Pneumonia
___Bloodclot

Areyoubeingtreatednoworhavebeentreatedfor__PPERSONAL,FAMILY,SOCIALHISTORY__
anyillness?Pleaselistthem.
1. __________________________________________PastMedHx
2. __________________________________________
3. __________________________________________
4. __________________________________________
5. __________________________________________

PCCSS, LLP|Pulmonary, Critical Care & Sleep Specialists

PULMONARYQUESTIONNAIRE

___________________PATIENT________________________CLINICIAN___________________

Haveyoueverhadanyoperations?Anyinjuries? PastSurgHx

1. __________________________________________
2. __________________________________________
3. __________________________________________
4. __________________________________________
5. __________________________________________

Checkifanyclosefamilymember(parents,siblingsandFamilyHx
Children)have:

___Heartproblems
___Diabetes
___Heartburn
___HighBloodPressure
___Cancer
Otherhealthproblems____________________________
________________________________________________

MaritalStatus S M W D SocialHx

Withwhomdoyoulive?____________________________
Whatisyouroccupation?___________________________
Whatareyourleisureactivities?_____________________
Whatisyoureducationlevel?_______________________

Tellusaboutyourriskoflungdisease.__________RRISKFACTORS__________
Pleasecheckifyouhave:
___Workedaroundtoxicchemicalsorsubstances
___Asbestosexposure
___Eversmoked
___Livedwithsomeonewhosmokes

Doyouexercise(includingwalking)?
___Yes___No

Hasaclosefamilymemberhadlungcancer,tubercolusis
oremphysema?
___Yes___No
Ifyes,who?____________________________________

Ifyouareawoman,haveyoupassedmenopause(change
oflife)?___Yes___No
Ifyes,atwhatage?______________________________
Doyoutakeestrogenreplacement?___Yes___No

PCCSS, LLP|Pulmonary, Critical Care & Sleep Specialists

PULMONARYQUESTIONNAIRE

___________________PATIENT________________________CLINICIAN___________________

Pleasetellusanythingelseaboutyourlungs:
________________________________________________
________________________________________________

Doyousmoke? HealthHabits:
___Yes___No
Ifyes,howmaypacksperday?____________________
Forhowmanyyears?____________________________
Ifyounolongersmoke,whendidyouquit?__________

Howmuchalcoholdoyoudrink?____________________

Doyouuseanyrecreationaldrugs?
___Yes___No
Ifyes,list:_____________________________________

Pleasetellusaboutyourmedicines(names,dosesor__MEDICINES,ALLERGIES,VACCINATIONS_
strength,howmanytimesaday).Includeoverthe
countermedicationsandmedicinethatyouverecently
stoppedtaking:
1. ________________________________________Medicines
2. ________________________________________
3. ________________________________________
4. ________________________________________
5. ________________________________________
6. ________________________________________
7. ________________________________________
8. ________________________________________
9. ________________________________________
10. ________________________________________
11. ________________________________________
12. ________________________________________
13. ________________________________________
14. ________________________________________
15. ________________________________________

Areyouallergictoanymedication:Allergies
___Yes___No
Ifyes,listmedicationstowhichyouareallergic&reactions:
1. _________________________________________
2. _________________________________________
3. _________________________________________
4. _________________________________________
5. _________________________________________

PCCSS, LLP|Pulmonary, Critical Care & Sleep Specialists

PULMONARYQUESTIONNAIRE

___________________PATIENT________________________CLINICIAN___________________

Doyouhavehayfever?
___Yes___No
Ifyes,whatkindofsymptomsdoyouexperience?
______________________________________________
______________________________________________

Haveyouhadthefollowingvaccinations?Vaccinations
___Influenza(FluShot)annually
___Pneumococcal(Pneumonia)Vaccine

Pleasecircleanysymptomyouhave,sowecanfindmoreaboutit:REVIEWOFSYMPTOMS__

Lackofenergy;daytimesleepiness,troublesleeping;Constitutional
Snoring;lossofappetite;weightchanges;fevers
Eyeproblems,suchasdoubleorblurredvision;glaucoma;HEENT
cataracts
Hearingproblems;buzzingorringinginears
Allergies;hayfever
Sinusproblems
Bloodpressureorheartproblems Cardiac
Asthma;tuberculosis Pulmonary
Stomachproblems;heartburn;indigestion;Gastrointestinal
changeinbowelhabits
Urinaryproblems;frequency,infections;stones;bladderGenitoUrinary
Men:Prostateproblems;nighttimeurination
Women:Abnormalmenstrualperiods;breastlumps;FemaleReproductive
couldyoubepregnant;recentmammogram,papsmear
orpelvicexam
Jointpains,swellingorredness;arthritis;backpainMusculoskeletal
Muscleachesortenderness;gout
Rash,itchingorotherskinproblemsDermatologic
Paralysis(eventemporary);numbness;lossofbalance;Neurologic
Seizures;lossofmemory;headaches;stroke;
Unusualthoughts;nervousness;cryingorsadness;Psychiatric
Suicideattempts;depression
Thyroiddisorder;diabetes;excessthirstorhunger;Endocrinologic
Frequenturination
Bleeding;easybruising;riskfactorsforHIV;anemia;cancerHematologic
Others:__________________________________________

Personallyreviewedbyme.Iagreewithorhaveamendeditsfindings.

____________________________________________
PhysicianSignature

PCCSS, LLP|Pulmonary, Critical Care & Sleep Specialists

PULMONARYQUESTIONNAIRE

___________________PHYSICALEXAMINATION________________

BP__________ PULSE_____ SpO2_____ RESP_____ T_____

GENERALAPPEARANCE_________________________________________________________________

N=NormalA=AbnormalD=DeferredDescriptionofAbnormalFindings

1) NOSE:Mucosa_____Turbinates_____Septum

2) MOUTH:Mucosa_____Teeth_____Gums_____
Tongue_____Pallate:Hard_____Soft_____
Tonsils_____PosteriorPharynx_____

3) NECK:Appearance_____Symmetry_____
TrachealPosition_____Crepitus_____
Thyroid_____JVD_____

4) RESPIRATORY:Inspect_____Symmetry_____
Percussion_____Palpation_____
Auscultation_____Effort_____

5) HEART:Apex_____Heave_____Thrill_____
Sounds_____Murmur_____Rub_____

6) ABDOMEN:Masses_____Tenderness_____
Liver_____Spleen_____BowelSounds_____

7) LYMPH:Neck_____Axilla_____Groin_____
Other(Specify)_____

8) MUSCULOSKELETAL/NEUROLOGIC:Gait_____
Station_____Strength_____Atrophy_____
Tone_____AbnormalMovement_____

9) EXTREMETIES:Varicosities_____Edema_____
Pulses_____Temp_____Tenderness_____
Digits_____Nails_____

10) SKIN:Scars_____Rashes_____
Describe___________________

11) NEUROPSYCH:Oriented_____Mood_____


NewPatient OfficeConsult
99201 15BulletPoints 99241
99202 611BulletPoints 99242
99203 1217BulletPoints 99243
99204AllItemswithGrayBorderand1 99244
99205ItemineachnonGrayBorder99245

PCCSS, LLP|Pulmonary, Critical Care & Sleep Specialists

PULMONARYQUESTIONNAIRE

___________________MEDICALDECISIONMAKING______________

DATAREVIEWED:

Lab(Date)
Hemoglobin___________
Electrolytes___________
Other(Specify)_________

PulmonaryFunctionTest(Date)________________________________________________

Bronchoscopy(Date)_________________________________________________________

Other(List/Date)____________________________________________________________

XRays(Date) PhysicianInterpretation:

__________Chest

__________CTChest

__________MRI

__________Other(ListType)

IMPRESSION:

PLAN: F/U___________

___PFT/Spirometry___
___V/QScan___
___ChestXray___
___NocturnalPulseOximetry
___Bronchoscopy
___Lab
___PulmRiskReduction
___CPEXLevel1___Level2___
Other_________________________

________________________________________________
PhysicianSignature

PCCSS, LLP|Pulmonary, Critical Care & Sleep Specialists